kmorriss
New
When a provider is doing a Medicare AWV's and addressing other chronic issues, would you give credit for the documentation in the plan to bill the separate E/M? The note in question has been provided below.
Subsequent Medicare Female AWV G0439
Lifestyle - normal amount of stress, normal sleep patterns, family not supportive and sporadic seatbelt use
Functional Ability - able to perform ADLs
Nutrition and Exercise - overweight, inadequate Vitamin D intake and inadequate calcium intake
End of Life Planning - has consented to end-of-life planning
Breast/Gyn Complaints - breast mass
Health Guidance - colonoscopy/sigmoidoscopy 2022 - to repeat in 5 years, DXA scan 2024 and regular mammogram 2022
Immunizations - influenza vaccine (annually 6 months of age and older) due, RSV due at pharmacy, Covid Vaccine due - decline, pneumococcal due at pharmacy, tetanus-diphtheria booster utd and zoster vaccine utd x2
I reviewed the documented medical, sdoh procedure, diagnostics and screening, surgical, drug allergy, family, medication, environment allergy, food allergy, immunization and social histories.
ROS:
Constitutional: The patient complained of fatigue, insomnia and weight gain/obesity but denied chills, fever, weight loss and recent illness.
Eyes: The patient denied eye problems, vision change and eye discharge.
Ears/Nose/Throat/Neck: The patient denied nasal discharge, otalgia, postnasal drip, sinus congestion and sore throat.
Cardiovascular: The patient denied chest pain/pressure and edema.
Respiratory: The patient denied cough, cigarette smoking/chews tob and passive smoking.
Gastrointestinal: The patient denied abdominal pain, nausea, vomiting, constipation and diarrhea.
Genitourinary/Nephrology: The patient denied dysuria.
Musculoskeletal: The patient complained of arthralgia(s) and leg pain/sciatica.
Dermatologic: The patient denied rash.
Neurologic: The patient complained of headache.
Psychiatric: The patient complained of depression but denied anxiety.
Vital Signs
Weight: 199 lbs clothed w/o shoes Height: 5' 5'' BMI: 33.1
Blood Pressure: 152/84 mmHg Right Arm Sitting Blood Pressure 2: 154/92 mmHg Left Arm Sitting
Sitting heart rate: 81 bpm Sitting radial regular
PE:
Constitutional
general appearance
Overall: in no acute distress
Nourishment: obese-android
Eyes
conjunctiva/eyelids
overall conjunctiva clear, cornea clear and eyelids normal
Ears/Nose/Throat
otoscopic exam
Overall: external auditory canals clear and tympanic membranes clear
internal nose
Overall: bilateral nasal cavities clear
oral cavity/pharynx/larynx
Posterior Pharynx: a normal exam
Oral mucosa: moist
Cardiovascular
auscultation of heart
Overall: regular rhythm, regular rate, normal heart sounds and no murmurs
Respiratory
auscultation
Overall: breath sounds clear bilaterally and no rales, rhonchi, wheezes
Musculoskeletal
gait and station
Overall: normal gait
Integument
inspection of skin
Overall: no rash, lesions
Lymphatic
neck nodes
Overall: anterior cervical chain benign, posterior cervical chain benign and supraclavicular chain benign
Psychiatric
mood and affect
Overall: normal mood and affect
Plan:
Annual Exam
Health Guidance
colonoscopy/sigmoidoscopy-2022 - to repeat in 5 years
DXA scan-2024-osteoporosis. Consider starting on Reclast.
regular mammogram-2022-pt to call BRH and schedule
Immunizations
influenza vaccine (annually 6 months of age and older)-due
RSV-due at pharmacy
Covid Vaccine-due - decline
pneumococcal-due at pharmacy
tetanus-diphtheria booster-utd
zoster vaccine-utd x2
screening labs today, along with UA-h/o renal cancer. Treated with partial nephroectomy.
Left ovarian fibroma-surgically removed-benign.
Mild depression-well controlled on Bupropion SR 100mg and Duloxetine 30mg
GERD-currently on pepcid and pantoprazole
HTN- on lisinopril 5mg NOT at goal less than 135/85
Subsequent Medicare Female AWV G0439
Lifestyle - normal amount of stress, normal sleep patterns, family not supportive and sporadic seatbelt use
Functional Ability - able to perform ADLs
Nutrition and Exercise - overweight, inadequate Vitamin D intake and inadequate calcium intake
End of Life Planning - has consented to end-of-life planning
Breast/Gyn Complaints - breast mass
Health Guidance - colonoscopy/sigmoidoscopy 2022 - to repeat in 5 years, DXA scan 2024 and regular mammogram 2022
Immunizations - influenza vaccine (annually 6 months of age and older) due, RSV due at pharmacy, Covid Vaccine due - decline, pneumococcal due at pharmacy, tetanus-diphtheria booster utd and zoster vaccine utd x2
I reviewed the documented medical, sdoh procedure, diagnostics and screening, surgical, drug allergy, family, medication, environment allergy, food allergy, immunization and social histories.
ROS:
Constitutional: The patient complained of fatigue, insomnia and weight gain/obesity but denied chills, fever, weight loss and recent illness.
Eyes: The patient denied eye problems, vision change and eye discharge.
Ears/Nose/Throat/Neck: The patient denied nasal discharge, otalgia, postnasal drip, sinus congestion and sore throat.
Cardiovascular: The patient denied chest pain/pressure and edema.
Respiratory: The patient denied cough, cigarette smoking/chews tob and passive smoking.
Gastrointestinal: The patient denied abdominal pain, nausea, vomiting, constipation and diarrhea.
Genitourinary/Nephrology: The patient denied dysuria.
Musculoskeletal: The patient complained of arthralgia(s) and leg pain/sciatica.
Dermatologic: The patient denied rash.
Neurologic: The patient complained of headache.
Psychiatric: The patient complained of depression but denied anxiety.
Vital Signs
Weight: 199 lbs clothed w/o shoes Height: 5' 5'' BMI: 33.1
Blood Pressure: 152/84 mmHg Right Arm Sitting Blood Pressure 2: 154/92 mmHg Left Arm Sitting
Sitting heart rate: 81 bpm Sitting radial regular
PE:
Constitutional
general appearance
Overall: in no acute distress
Nourishment: obese-android
Eyes
conjunctiva/eyelids
overall conjunctiva clear, cornea clear and eyelids normal
Ears/Nose/Throat
otoscopic exam
Overall: external auditory canals clear and tympanic membranes clear
internal nose
Overall: bilateral nasal cavities clear
oral cavity/pharynx/larynx
Posterior Pharynx: a normal exam
Oral mucosa: moist
Cardiovascular
auscultation of heart
Overall: regular rhythm, regular rate, normal heart sounds and no murmurs
Respiratory
auscultation
Overall: breath sounds clear bilaterally and no rales, rhonchi, wheezes
Musculoskeletal
gait and station
Overall: normal gait
Integument
inspection of skin
Overall: no rash, lesions
Lymphatic
neck nodes
Overall: anterior cervical chain benign, posterior cervical chain benign and supraclavicular chain benign
Psychiatric
mood and affect
Overall: normal mood and affect
Plan:
Annual Exam
Health Guidance
colonoscopy/sigmoidoscopy-2022 - to repeat in 5 years
DXA scan-2024-osteoporosis. Consider starting on Reclast.
regular mammogram-2022-pt to call BRH and schedule
Immunizations
influenza vaccine (annually 6 months of age and older)-due
RSV-due at pharmacy
Covid Vaccine-due - decline
pneumococcal-due at pharmacy
tetanus-diphtheria booster-utd
zoster vaccine-utd x2
screening labs today, along with UA-h/o renal cancer. Treated with partial nephroectomy.
Left ovarian fibroma-surgically removed-benign.
Mild depression-well controlled on Bupropion SR 100mg and Duloxetine 30mg
GERD-currently on pepcid and pantoprazole
HTN- on lisinopril 5mg NOT at goal less than 135/85